P1: FLF Journal of Genetic Counseling [jgc]
HS105-81
August 17, 2000
16:2
Style file version Nov. 19th, 1999
Journal of Genetic Counseling, Vol. 9, No. 5, 2000
The Experience of Leader-Led Peer Supervision: Genetic Counselors’ Perspectives Elaine Hiller1,2 and Janet M. Rosenfield3
As we proceed through our professional lives, it is essential that we challenge ourselves in order to continue to develop our genetic counseling skills. Conferences, workshops, post-graduate courses, journal clubs, and involvement in professional organizations have become the traditional methods of continuing education for post-graduate genetic counselors. While these forums address the need to stay updated on scientific or information-based topics, there is little available to counselors to promote growth in counseling skills. A group of Boston-based genetic counselors describe how their leader-led supervision group has established a setting to meet the needs of its members both for support and continued counseling training. We outline here the evolution of this group and how it has become a valued part of our professional lives. We feel that the model of leader-led peer supervision holds great value in helping genetic counselors continue to enhance their interpersonal skills in a supportive, safe, and challenging environment. It is our hope that others will elect to form similar groups in their own communities, thereby creating new opportunities for growth within the genetic counseling profession. KEY WORDS: supervision; supervision group; genetic counseling.
INTRODUCTION Supervision groups for counseling professionals, including psychiatrists, psychologists, and social workers, have become a valued part of professional development and support within these professions over the past twenty years. Dr. Annette Kennedy, a clinical psychologist and past instructor in the Genetic Counseling 1 Department 2 Faculty,
of Adult Oncology, Dana Farber Cancer Institute, Boston, Massachusetts. Genetic Counseling Program, Brandeis University, Waltham, Massachusetts.
3 Correspondence should be directed to Janet M. Rosenfield, 158 Prince Street, Newton, Massachusetts
02165; e-mail: [email protected]. 399 C 2000 National Society of Genetic Counselors, Inc. 1059-7700/00/1000-0399$18.00/1 °
P1: FLF Journal of Genetic Counseling [jgc]
HS105-81
August 17, 2000
16:2
Style file version Nov. 19th, 1999
400
Hiller and Rosenfield
Program at Brandeis University (1992–99) approached the genetic counselors in the Boston area to suggest the formation of such a group. In time, six agreed to join her. The original commitment was for six sessions, meeting every other week, beginning in January 1997. We are still meeting today (May 2000). Clearly, the group has more than met the expectations of its participants. It is our hope that this paper in conjunction with the others in this issue of the Journal of Genetic Counseling will motivate genetic counselors to form supervision groups in their own communities. Please refer to Dr. Kennedy’s papers in this issue of the Journal for a discussion of the theoretical underpinnings and history of various types of supervision, their applicability to the field of genetic counseling, and the logistical details of our particular group. Creating a safe yet challenging environment in which to continue the learning process has dramatically enriched our professional development and our relationships with colleagues. Because of our positive experience, we wish to “get the word out” so that others may benefit by participation in supervision groups. What follows is a description of the group’s early history, as well as details of some important transitional moments, which have moved the group forward over the past three and a half years. Here, we briefly summarize the shared experience from the counselors’ perspectives. This description is experiential not scientific and its value lies in showing what is possible in leader-led supervision.
EARLY EXPECTATIONS AND HOPES Each of us had her own reasons for deciding to join the supervision group and each had a unique set of expectations and hopes about what lay ahead. Of the several hopes and expectations that were articulated during our early meetings, a few were common to all of us. The first hope was for time to process cases. Some of us work with other genetic counselors while others do not, but all of us felt a noticeable absence of process time at work. Busy days, constant interruptions, and the emphasis on tangible productivity leave little time for reflection during a counselor’s workday. We felt the need for a place and time to slow down and extract the richness and the lessons from what we do every day. A second hope was for a safe outlet, a supportive place to take our most challenging and emotionally charged cases. The work of genetic counseling can be draining and is difficult for those outside of the profession to understand. All of us were familiar with the fact that taking cases home emotionally interferes with personal time and can contribute to professional burnout. Other sources of burnout and job-related stress were problems within our work settings and patient care dilemmas. We hoped that the group would represent a place to manage some of the intensity of our jobs.
P1: FLF Journal of Genetic Counseling [jgc]
HS105-81
August 17, 2000
16:2
The Experience of Leader-Led Peer Supervision
Style file version Nov. 19th, 1999
401
Finally, an important expectation and hope for supervision could be summed up under the heading of “professional development” or “continuing education.” Each of us wanted to learn from our colleagues, from Dr. Kennedy, and from the supervision process itself. Ultimately, the goal for each of us was to become a better genetic counselor. Receiving critical analysis and feedback about our most challenging cases and participating in comprehensive reviews of others’ cases seemed an ideal approach. Each of us had hopes of improving specific aspects of counseling technique, learning more about counseling theory, and having the opportunity to synthesize theory with practice. The fact that our group is still going strong in its fourth year is a clear indication that our hopes and expectations have been more than met. We wondered whether there would be enough material to discuss when we made the initial commitment to meet for six sessions. It is now difficult for us to believe that this concern ever existed.
EARLY CONCERNS In the beginning, each of us had some fears and concerns about committing to the supervision group. The logistical worries included finding the necessary time and money for the sessions. Making a commitment to the group involved spending our own money and carving out valued personal time. No one received monetary or work-hour compensation for her involvement in the group. Some of us wondered if the group represented a luxury or an indulgence. Although the logistical concerns were real, they may well have also represented a cover for the deeper concern each of us felt about making ourselves vulnerable to critique. Each counselor was aware that she would be revealing aspects of her counseling technique that had not been reviewed since graduate school. Because counseling style and approach are subjective and personal, there was a great deal at stake in discussing cases. Would we be able to share insecurities, confront weaknesses, and acknowledge strengths? Would our colleagues and Dr. Kennedy judge specific counseling interventions as “up to par?” Would individual cases be viewed as too ordinary? Would our individual observations be seen as obvious points? These concerns were expressed universally by the group members irrespective of counseling experience, which ranged from two to seventeen years. Case presentations and critiques represent a highly personal form of judgment of our skills. Deficits in our scientific or information-based knowledge are relatively easy to remedy; perceived deficits in our interpersonal skills regarding complex cases and clients go to our cores as counselors and as human beings. Interestingly, each of us was concerned with the ways in which her own level of clinical experience would influence group dynamics as well as her ability to
P1: FLF Journal of Genetic Counseling [jgc]
402
HS105-81
August 17, 2000
16:2
Style file version Nov. 19th, 1999
Hiller and Rosenfield
contribute to the group. For more recent graduates, the worries took the form of a perceived “lack of experience”: Would they have as much to contribute? Would their interventions be viewed as less insightful? Others had changing job situations and were concerned that their different responsibilities would mean that they would have less to offer the group. Still others worried that differences in experience might translate into a hierarchy within the group that would have a negative impact on our interactions. In making the financial and time commitment to create this group, we recognized that we would need to invest even more at an emotional level in order to get our “money’s worth.” The hope was that in taking the risk to reveal ourselves, the value gained through our discussions and the safety provided by the setting would far exceed any personal discomfort we might experience.
EXPERIENCES OF GROUP MEMBERS Dr. Kennedy was instrumental in assembling the supervision group. She contacted each of us individually after hearing of our interest and provided a template for how the group would function. During our first meeting, she supported our hopes for what the group could become by sharing her own experience with postgraduate clinical supervision and its value in her professional life. She listened carefully to our concerns. She focused on concrete elements such as the proposed structure for the group and the value of case review in a counseling context. Without a long-term commitment, we had the freedom to view the first six sessions as a trial period and to see just where the group would go. Creating the supervision group became do-able. We did not feel overwhelmed by either our expectations or our concerns. The first group meeting was decidedly awkward. Although we all knew each other to varying degrees, this was a brand new and somewhat intimidating context. The existing relationships among various members added a challenge to the task of forming a group of equals or peers. Some of us had met each other only in passing at professional conferences, while others were colleagues at the same work site or even had long-standing friendships. Two of the counselors had served as supervisors to a third during her student internships. Some of us had been Dr. Kennedy’s students at Brandeis University. We would eventually come to be able to discuss these very issues as part of our process, but during the first meeting, we needed to reintroduce ourselves to each other in the context of this new setting. The source of our equality became clear in the form of our goals; each of us, regardless of experience, wanted to keep growing professionally and had chosen this format in which to do it. During this first meeting, we took time to individually describe our counseling practices and work settings as well as our goals for supervision.
P1: FLF Journal of Genetic Counseling [jgc]
HS105-81
August 17, 2000
The Experience of Leader-Led Peer Supervision
16:2
Style file version Nov. 19th, 1999
403
The first six sessions, occurring over twelve weeks, passed quickly. Each of the six participants had the opportunity to present one or two cases during that time. By the end of the twelve weeks, all of us wanted to continue because we had benefited from those first meetings. We all wanted to present other cases. It seemed clear that the first six meetings represented just the tip of a very intriguing and productive iceberg. With the high level of interest in continuing the group, it was necessary to establish guidelines for going forward including procedures for leaving the group and bringing new members aboard. Specifically, if a member wished to leave the group, that member could not leave abruptly. We agreed that a period of two to three more meetings would be necessary to process the leaving and say goodbye. Likewise, if someone were interested in joining the group, she would be referred to Dr. Kennedy who would then approach the group members regarding the possibility of adding a new member. This discussion might also span two to three sessions. A group consensus was necessary for inclusion of a new member to the group. It was also agreed upon that we would periodically devote group time to a discussion of ways in which to ensure that the group continued to meet our needs and sustain our interest. This review would begin with a presentation by Dr. Kennedy of a compilation of themes that had surfaced in our discussions. Also as a part of the periodic review, group members would discuss the impact of the group for each of us individually. Several factors have contributed to the longevity of our supervision group. Simply stated, our expectations were exceeded and our fears proved largely unfounded. The safety and trust that now exists within the group grew incrementally. An early event indicating trust occurred with a shift from presenting past cases to current problematic cases. If it is difficult to open oneself up to scrutiny about events that are long over, it is doubly difficult to do so with ongoing cases. While building a safe environment was essential in the beginning, once established it allowed us to critique and challenge each other. Gradually, we found ourselves able to raise very sensitive issues for discussion, including job frustrations and personal challenges and how they affected our work. We changed the group format by devoting time at the beginning for updates and new thoughts about old cases. It also became “open” time for us to bring up important personal issues and milestones. Settling into this new format allowed us to continue to connect to one another personally and professionally. The group has established a safe environment in large part because we set appropriate boundaries and the members respected those boundaries. As the trust in those boundaries grew, so did our willingness to take risks. As part of the original contract, we all agreed that we would not discuss the group or issues raised by the group with “outsiders.” We also agreed that we would not discuss issues or dynamics important to the entire group with one or just a few members of the group. Our concern was that this might lead to an unhealthy change in group dynamics. There was the acknowledged issue of patient and professional
P1: FLF Journal of Genetic Counseling [jgc]
404
HS105-81
August 17, 2000
16:2
Style file version Nov. 19th, 1999
Hiller and Rosenfield
confidentiality, but moreover there was the need to demonstrate respect for our colleagues. It is likely that the shift to on-going cases is connected to the establishment of appropriate boundaries. We all had to know that the group could hear our most challenging and troubling cases. Since we are being critiqued without being judged, we can experience the group discussion as helpful in strategizing the next step. In addition, we can prod each other to seek greater understanding of what happened in our sessions and, more importantly, our reactions to those events. We take new insights back to our work settings and incorporate them in ways that work for us individually. We remain individuals with distinct counseling styles that are not fundamentally altered, but are augmented by group feedback. The knowledge that we may take risks without being personally attacked makes the group setting safe and creates the space for personal growth and professional development. With a shift from past cases to current cases, the emphasis is placed on interventions that can be actively employed. We accomplish this through the use of role-play, journal reading to apply theory, suggesting and “trying on” interventions, and providing support. Each of these facilitates conscious awareness of factors that may obstruct the counseling process. Using role-play and integrating theory can help an individual counselor change her approach to a difficult patient or set of circumstances. Continuity is provided by the time devoted to follow-up at the beginning of each supervision session. This establishes a comfortable flow and a connection to our past cases and to each other. While the supportiveness of the group has been tremendously important to its success and longevity, we do challenge each other. One form that this takes is a probing assessment of interventions that have been employed by the presenter and the suggestion of alternative approaches. This is true both for finished cases and for those that are ongoing. Examples of questions designed to challenge are “What if you had said . . . to this patient?” or “If you had done . . . instead of the intervention used, how do you think the interaction would have changed?” This approach solicits creative thinking about cases and may involve imagining several alternative interventions. We try to include interventions that are unconventional, provocative, or even outrageous as an exercise to stretch our own limits, even though many approaches would never be employed in a counseling session. On occasion, roleplay has been especially useful. In one instance, a counselor was dreading making a phone call to a particularly demanding and unpredictable patient. Role-playing the call and a number of possible interactions gave her the opportunity to practice and solidify her approach to a potentially unpleasant and difficult interaction. It also gave the group a chance to critically examine the counselor’s proposed approaches, suggest other possibilities, and ask her to “report back” about the phone call at the next meeting. In addition to assessing the specifics of patient interactions in particular cases, we challenge each other to identify and address our own biases, patterns, and issues,
P1: FLF Journal of Genetic Counseling [jgc]
HS105-81
August 17, 2000
The Experience of Leader-Led Peer Supervision
16:2
Style file version Nov. 19th, 1999
405
particularly those that might produce obstacles to the counseling process. We try to press beyond what is apparent in the case and examine our own defenses, reactions to patients, and perceptions of ourselves as counselors. Examples of questions that get at these issues are “Why was the interaction with this patient difficult for you?” “Did this patient behave in a manipulative way or did you allow yourself to be manipulated?” “Did you make assumptions about the patient based on ethnicity/class/gender/age?” “How has your personal or family experience with chronic illness affected your interaction with this patient?” All of these questions fall broadly under the heading of “Don’t you think that there is something else going on here?” and can be some of the most uncomfortable and revealing to discuss. One group member presented a case in which she felt that she had abandoned her opinions about a case and her role in patient care too easily when she disagreed with a physician at work. Lengthy discussion in the group revealed that the counselor has had a pattern of “abdication” to perceived authority and of undervaluing herself professionally. Each of us feels some anxiety about presenting difficult cases and being in the “hot seat” as the counselor to be critiqued during a meeting. This would not be the case if our group were simply a comfortable social gathering. However, we do not believe that supervision must always be painful or can never be fun. In fact, we find that we often use humor as a way to manage tension about a case, feelings of inadequacy, or interactions in the group that become heated or uncomfortable. At the same time, we try to be aware of these light moments and the purpose that they are serving and not hide behind humor. Some sessions are less personally challenging than others and we do not subscribe to a “no pain, no gain” philosophy. There is great value in the amount of time and depth of discussion that we are able to give to each case. It is a delicate balance of support and criticism, humor and seriousness that allows our group to function.
KEY MOMENTS The accompanying articles include three detailed descriptions of case presentations that will provide the reader with more sense of the workings of our supervision group. In this section, we describe several developments or situations that were pivotal to the evolution of our group. They represent only a small sample of the many events that have shaped the group. Early in the development of the group, it took some time to settle on the best format for the use of our hour and a half together. Initially, we tried to have two case presentations in a single evening. We soon realized that there was always enough material from a single case to fill the entire time in a satisfying way. In fact, trying to get through two presentations felt like a push; feeling rushed and hectic was the last thing that we wanted for our processing time. The format of
P1: FLF Journal of Genetic Counseling [jgc]
406
HS105-81
August 17, 2000
16:2
Style file version Nov. 19th, 1999
Hiller and Rosenfield
one case per session, with time at the beginning for updates and news, was a very productive one for us. More recently, we have elected to meet once a month for two hours. The format is essentially the same except we now have time to present a second case. We found that scheduling conflicts were frequent when we attempted to meet every other week. We are still in the “trying out” phase of this latest arrangement and suspect it will continue to change over time as the needs of the group change. At the end of the first year, there was a general consensus that we would like to “take it to the next level” and challenge ourselves further. One approach to doing this, suggested by Dr. Kennedy, was to incorporate articles from the psychology and counseling literature into our case presentations. In this way, cases may be discussed and explored within particular theoretical frameworks. Some of the articles and chapters that we have used are listed in Appendix A. The majority of this list has come from a core set of readings provided by Dr. Kennedy. However, group members have added articles of personal interest and relevance to our cases. Not every case is presented along with literature or theory, but this gives us an option for enriching presentations. For cases involving issues of suicide, guilt and shame, and personality disorders—to name a few—incorporating articles from the literature has been invaluable for centering our discussions. In addition to incorporating theory, an approach that we have just begun to use is to specifically analyze our personal biases and explore how they may surface in the handling of particular cases. All people, counselors included, hold strong beliefs about disability, religion, socioeconomic status, ethnicity, and race among many other issues. By consciously examining these beliefs, we can come to understand how they may surface in our counseling sessions in obstructive ways. While it is not the aim of the group to work through or alter the biases of its members, we do try to help each other identify areas where personal issues may affect counseling approach. While acknowledging that we all have biases, we try to develop strategies to manage their influence on our counseling interactions. Another example of stretching the limits of the group occurred in response to a counselor’s request that Dr. Kennedy present a case from her own practice. This has not become a regular feature of the group and, as a regular occurrence, would not fit within the usual boundaries of the facilitator’s role. However, this one case presentation allowed Dr. Kennedy to share of herself in a more personal way and gave the group a better appreciation for her counseling style and interventions. Dr. Kennedy became more real to us as a therapist. As she shared her thoughts and feelings about her patient—and her own experience in clinical supervision—we could see that professional development is always a work in progress, requiring attention and continual refinement. Countless situations and discussions have engendered the closeness and trust that we now feel, but several stand out in our memories. On one occasion, a group member described how she cried in front of a student in her office after a
P1: FLF Journal of Genetic Counseling [jgc]
HS105-81
August 17, 2000
16:2
The Experience of Leader-Led Peer Supervision
Style file version Nov. 19th, 1999
407
particularly sad session with a patient. This had felt to her at the time like a loss of control, a “break-down,” even an unprofessional loss of composure. The group affirmed the humanity and validity of her reaction and the possible benefits for her student of seeing a supervisor care about a patient so deeply. On another occasion, the group was able to openly discuss the differences in experience among its members as well as discomfort experienced by the change in some of our relationships from pregroup associations. The honesty caused many barriers to fall that evening. A former “student” felt more comfortable commenting on her “supervisor’s” cases. Group members who were not currently seeing patients were reassured that they made as valuable a contribution as those who were. We reached the sincere consensus that diversity in all areas—clinical experience, temperament, counseling style, personal circumstances—enriches the group a great deal. Still another session dealt with the extreme job-related stress faced by one member whose work demands had become unreasonable. All of us had discussed to some extent feelings of burnout, isolation, or being undervalued, but those feelings crystallized that night in her situation. The group helped bolster her resolve to be assertive enough to ask for the specific changes at work that would make her circumstances more pleasant, and in fact she did get much of what she asked for. The group also assured her that her current situation did not reflect negatively on her as a counselor and that no one would be able to fulfill all of the expectations placed upon her. It became increasingly clear that not only was it acceptable for her to ask for reasonable changes at work, but that in fact it was necessary in order for her to take care of herself. Some issues have surfaced in the context of particular cases that have served to strengthen the bonds within the group. One member expressed feeling guilty about the fact that she occasionally has patients that she simply doesn’t like, leading to the acknowledgment that this was a situation common to all of us. It was a relief to share this sentiment and process it, realizing along the way that it doesn’t diminish us as genetic counselors and that we are still able to provide good care to these patients. Many cases have involved feelings of failure; all of us have wished that we could have helped a patient more, handled interactions with a couple better, or felt more competent with a manipulative or intimidating patient. The group has been consistently effective in turning these perceived failures into learning opportunities.
SUPERVISION TOPICS We have surprised ourselves with the number of topics that we bring to the group. Table I represents a brief sampling of those issues. Some issues seem to continually reemerge because they represent the situations and crises that are faced
P1: FLF Journal of Genetic Counseling [jgc]
HS105-81
August 17, 2000
16:2
Style file version Nov. 19th, 1999
408
Hiller and Rosenfield Table I. Examples of Discussion Topics Patient-related issues Challenging patients Learning disabilities Mental illness and personality disorders Mental retardation Suicidality and suicide Domestic violence Level of directiveness Counselor-related issues Work environment Transference and counter-transference Confidentiality Reframing issues Personal biases Personal /professional boundaries Burnout Group process Student supervision
by people seeking genetic counseling. Others seem to be inherent to the experience of counselors or the interactions between counselor and patient. It is never dull or wasteful to revisit the same general topics because what can be gleaned from a given case depends upon so many factors. We change over time, our jobs change, and each patient interaction is unique. CONCLUSION The model of leader-led peer supervision, long used in other mental health professions, has proven to be a rewarding format for this group of genetic counselors. It is well suited to the professional development needs of genetic counselors and is a particularly appropriate way to address growth in counseling skills; many avenues already exist for keeping current in the scientific component of our profession. While we are eager to tell our colleagues about the success of our group, it is important to add that we needed time together in order for our group to come to this stage of development. A newly formed group would need to acknowledge that the connection to one’s colleagues and the commitment to the supervision process occur in stages. The first few cases presented are the most difficult and everyone will not move at the same pace. As with our clients, some of us share personal difficulties more readily than others do. Each group will also need to experiment and find the correct format and style to fit the needs of its members. We have found our supervision group to be such a worthwhile endeavor that the inevitable growing pains experienced in the beginning have been far outweighed by the benefits.
P1: FLF Journal of Genetic Counseling [jgc]
HS105-81
August 17, 2000
The Experience of Leader-Led Peer Supervision
16:2
Style file version Nov. 19th, 1999
409
APPENDIX A Baker DL, Schuette JL, Uhlmann WR (1998) A Guide to Genetic Counseling. New York: Wiley-Liss. Bronfenbrenner U (1977) Toward an experimental ecology of human development. American Psychologist 32:513–531. Carter B, McGoldrick M (1988) Overview. In: The changing family life cycle: A framework for family therapy. New York: Gardner, pp 3–28. Cohen R (1994) About men: Waiting. The New York Times Magazine Jan 16. Eunpu DL (1997) Systemically-based psychotherapeutic techniques in genetic counseling. J Genet Couns 6:1–20. Erikson EH (1963) Eight ages of man. In: Childhood and Society. New York: WW Norton & Co. Finucane B (1998) Working with women who have mental retardation: A genetic counselor’s guide. Elwyn: Elwyn, Inc. Gilligan C (1993) Concepts of self and morality. In: In a different voice. Cambridge: Harvard University Press. Glossary of specific defense mechanisms and coping styles (1994) In: Diagnostic and statistical manual of mental disorders, 4th ed (DSM-IV). Washington, DC: American Psychiatric Association, pp 755–757. Green R (1992) Letter to a genetic counselor. J Genet Couns 1:55–69. Green R (1994) Another letter to a genetic counselor. In: A Heartbreaking Choice. St. John’s, MI: Pineapple Press. Hamilton NG (1992) Countertransference. In: Self and others: Object relations theory in practice. New Jersey: Aronson, pp 235–250. Horowitha M, Marmar C, Krupnick J, Wilner N, Kaltrieder N, Wallerstien R (1984) Our approach to brief therapy: Focused on current stressors. In: Personality styles and brief psychotherapy. New York: Basic Books, pp 34–50. Hoyt MF, Rosenbaum R, Talmon M (1992) Planned single-session psychotherapy. In: Budman SH, Hoyt MF, Freidman S (eds) The First Session in Brief Therapy. New York: Guilford, pp 59–86. Jordan JV (1991) Empathy and the mother-daughter relationship. In: Jordan JV, Kaplan AG, Miller JB, Stiver IP, Surrey JL Women’s growth in connection: Writings from the Stone Center. New York: Guilford, pp 28–34. Kessler S (1979) The genetic counselor as psychotherapist. Birth Defects: Original article series (The National Foundation) 25:187–200. Kessler S, Kessler H, Ward P (1984) Psychological aspects of genetic counseling III: Management of guilt and shame. Amer J Med Genet 17:673–697. Kessler S (1972) Psychological Aspects of Genetic Counseling VII: Thoughts on Directiveness. J Genet Couns 1:9–17. Kessler S (1997) Psychological aspects of genetic counseling IX: Teaching and counseling. J Genet Couns 6:287–295. Kessler S (1997) Psychological aspects of genetic counseling X: Advanced counseling techniques. J Genet Couns 6:379–392. Kessler S (1997) Psychological aspects of genetic counseling XI: Nondirectiveness revisited. Amer J Med Genet 72:164–171. Kessler S (1998) Psychological aspects of genetic counseling XII: More on counseling skills. J Genet Couns 7:263–278. Kluger-Bell K (1998) Lost fathers: Men’s experience of pregnancy loss and abortion. In: Unspeakable losses: Understanding the experience of pregnancy loss, miscarriage and abortion, pp 99–117 & pp 135–147. Massie RK, Jr (1985) The constant shadow: Reflections on the life of a chronically ill child. In: Hobbs N, Perrin J (eds) Issues in the care of children with chronic illness. San Francisco: Jossey-Bass, pp 13–23. Matloff ET, Eunpu DL, Djurdjinovic L (1997) Generations lost: A cancer genetics case report and commentaries. J Genet Couns 6:169–180. McGoldrick M (1982) Ethnicity and family therapy: An overview. In: McGoldrick M, Pearce JK, Giordano J (eds) Ethnicity and family therapy. NY: Guilford, pp 3–30.
P1: FLF Journal of Genetic Counseling [jgc]
410
HS105-81
August 17, 2000
16:2
Style file version Nov. 19th, 1999
Hiller and Rosenfield
Michie S, Marteau TM (1996) Predictive genetic testing in children: The need for psychological research. Brit J Health Psychology 1:3–14. Mitchell DR (1985) Guidance needs and counseling of parents of persons with intellectual handicaps. In: Singh NN, Wilton KM (eds) Mental retardation in New Zealand: Provisions, services and research. Christchurch, New Zealand: Whitcoulls, pp 136–156. Noble JH (1987) Ethical considerations facing society in rehabilitating severely disabled persons. In: Ferrari M, Sussman M (eds) Childhood disability and family systems. New York: Haworth, pp 65–81. Olson DH, Russell CS, Sprenkle DH (1983) Circumplex model of marital and family systems VI: Theoretical update. Family Process 22:69–83. Perry CH (1982) Models of development, relationship and therapy in the work of Donald Winnicott. Unpublished manuscript. Peters JA (1994) Suicide prevention in the genetic counseling context. J Genet Couns 3:199–213. Peters-Brown T, Fry-Mehltretter L (1996) Genetic counseling for pregnant adolescents. J Genet Couns 5:155–168. Pipes RB, Davenport DS (1990) Transference/countertransference. In: Introduction to psychotherapy. Englewood Cliffs: Prentice Hall, pp 151–166. Pueschel SM (1991) Ethical considerations relating to prenatal diagnosis of fetuses with Down Syndrome. Mental Retardation 29:185–190. Sedney MA, Baker JE, Gross E (1994) “The story” of a death: Therapeutic considerations with bereaved families. J Marital Fam Ther 20:287–296. Surrey JL (1991) Empathy and the mother-daughter relationship. In: Jordan JV, Kaplan AG, Miller JB, Stiver IP, Surrey JL Women’s growth in connection: Writings from the Stone Center. New York: Guilford, pp 51–66. VanPutte AW (1988) Perinatal bereavement crisis: Coping with negative outcomes from prenatal diagnosis. J Perinatal Neonatal Nursing 2:12–22. Welshimer KJ, Earp JL (1989) Genetic counseling within the context of existing attitudes and beliefs. Patient Education Couns 13:237–255. Wikler L, Wasow M, Hatfield E (1981) Chronic sorrow revisited: Parent vs. professional depiction of the adjustment of parents of mentally retarded children. Amer J Orthopsychiatry 51:63–70. Wikler L (1981) Chronic stresses of families of mentally retarded children. Fam Relations 30:281–288. Wikler L, Wasow M, Hatfield E (1983) Seeking strengths in families of developmentally disabled children. Social Work 28:313–315. Worden JW (1991) Grief counseling: Facilitating uncomplicated grief. In: Grief counseling and grief therapy: A handbook for the mental health practitioner, 2nd ed. New York: Springer, pp 37–62. Yarborough M, Scott JA, Dixon LK (1989) The role of beneficence in clinical genetics: non-directive counseling reconsidered. Theoretical Medicine 10:139–149.
HS105-81
August 17, 2000
16:2
Style file version Nov. 19th, 1999
Journal of Genetic Counseling, Vol. 9, No. 5, 2000
The Experience of Leader-Led Peer Supervision: Genetic Counselors’ Perspectives Elaine Hiller1,2 and Janet M. Rosenfield3
As we proceed through our professional lives, it is essential that we challenge ourselves in order to continue to develop our genetic counseling skills. Conferences, workshops, post-graduate courses, journal clubs, and involvement in professional organizations have become the traditional methods of continuing education for post-graduate genetic counselors. While these forums address the need to stay updated on scientific or information-based topics, there is little available to counselors to promote growth in counseling skills. A group of Boston-based genetic counselors describe how their leader-led supervision group has established a setting to meet the needs of its members both for support and continued counseling training. We outline here the evolution of this group and how it has become a valued part of our professional lives. We feel that the model of leader-led peer supervision holds great value in helping genetic counselors continue to enhance their interpersonal skills in a supportive, safe, and challenging environment. It is our hope that others will elect to form similar groups in their own communities, thereby creating new opportunities for growth within the genetic counseling profession. KEY WORDS: supervision; supervision group; genetic counseling.
INTRODUCTION Supervision groups for counseling professionals, including psychiatrists, psychologists, and social workers, have become a valued part of professional development and support within these professions over the past twenty years. Dr. Annette Kennedy, a clinical psychologist and past instructor in the Genetic Counseling 1 Department 2 Faculty,
of Adult Oncology, Dana Farber Cancer Institute, Boston, Massachusetts. Genetic Counseling Program, Brandeis University, Waltham, Massachusetts.
3 Correspondence should be directed to Janet M. Rosenfield, 158 Prince Street, Newton, Massachusetts
02165; e-mail: [email protected]. 399 C 2000 National Society of Genetic Counselors, Inc. 1059-7700/00/1000-0399$18.00/1 °
P1: FLF Journal of Genetic Counseling [jgc]
HS105-81
August 17, 2000
16:2
Style file version Nov. 19th, 1999
400
Hiller and Rosenfield
Program at Brandeis University (1992–99) approached the genetic counselors in the Boston area to suggest the formation of such a group. In time, six agreed to join her. The original commitment was for six sessions, meeting every other week, beginning in January 1997. We are still meeting today (May 2000). Clearly, the group has more than met the expectations of its participants. It is our hope that this paper in conjunction with the others in this issue of the Journal of Genetic Counseling will motivate genetic counselors to form supervision groups in their own communities. Please refer to Dr. Kennedy’s papers in this issue of the Journal for a discussion of the theoretical underpinnings and history of various types of supervision, their applicability to the field of genetic counseling, and the logistical details of our particular group. Creating a safe yet challenging environment in which to continue the learning process has dramatically enriched our professional development and our relationships with colleagues. Because of our positive experience, we wish to “get the word out” so that others may benefit by participation in supervision groups. What follows is a description of the group’s early history, as well as details of some important transitional moments, which have moved the group forward over the past three and a half years. Here, we briefly summarize the shared experience from the counselors’ perspectives. This description is experiential not scientific and its value lies in showing what is possible in leader-led supervision.
EARLY EXPECTATIONS AND HOPES Each of us had her own reasons for deciding to join the supervision group and each had a unique set of expectations and hopes about what lay ahead. Of the several hopes and expectations that were articulated during our early meetings, a few were common to all of us. The first hope was for time to process cases. Some of us work with other genetic counselors while others do not, but all of us felt a noticeable absence of process time at work. Busy days, constant interruptions, and the emphasis on tangible productivity leave little time for reflection during a counselor’s workday. We felt the need for a place and time to slow down and extract the richness and the lessons from what we do every day. A second hope was for a safe outlet, a supportive place to take our most challenging and emotionally charged cases. The work of genetic counseling can be draining and is difficult for those outside of the profession to understand. All of us were familiar with the fact that taking cases home emotionally interferes with personal time and can contribute to professional burnout. Other sources of burnout and job-related stress were problems within our work settings and patient care dilemmas. We hoped that the group would represent a place to manage some of the intensity of our jobs.
P1: FLF Journal of Genetic Counseling [jgc]
HS105-81
August 17, 2000
16:2
The Experience of Leader-Led Peer Supervision
Style file version Nov. 19th, 1999
401
Finally, an important expectation and hope for supervision could be summed up under the heading of “professional development” or “continuing education.” Each of us wanted to learn from our colleagues, from Dr. Kennedy, and from the supervision process itself. Ultimately, the goal for each of us was to become a better genetic counselor. Receiving critical analysis and feedback about our most challenging cases and participating in comprehensive reviews of others’ cases seemed an ideal approach. Each of us had hopes of improving specific aspects of counseling technique, learning more about counseling theory, and having the opportunity to synthesize theory with practice. The fact that our group is still going strong in its fourth year is a clear indication that our hopes and expectations have been more than met. We wondered whether there would be enough material to discuss when we made the initial commitment to meet for six sessions. It is now difficult for us to believe that this concern ever existed.
EARLY CONCERNS In the beginning, each of us had some fears and concerns about committing to the supervision group. The logistical worries included finding the necessary time and money for the sessions. Making a commitment to the group involved spending our own money and carving out valued personal time. No one received monetary or work-hour compensation for her involvement in the group. Some of us wondered if the group represented a luxury or an indulgence. Although the logistical concerns were real, they may well have also represented a cover for the deeper concern each of us felt about making ourselves vulnerable to critique. Each counselor was aware that she would be revealing aspects of her counseling technique that had not been reviewed since graduate school. Because counseling style and approach are subjective and personal, there was a great deal at stake in discussing cases. Would we be able to share insecurities, confront weaknesses, and acknowledge strengths? Would our colleagues and Dr. Kennedy judge specific counseling interventions as “up to par?” Would individual cases be viewed as too ordinary? Would our individual observations be seen as obvious points? These concerns were expressed universally by the group members irrespective of counseling experience, which ranged from two to seventeen years. Case presentations and critiques represent a highly personal form of judgment of our skills. Deficits in our scientific or information-based knowledge are relatively easy to remedy; perceived deficits in our interpersonal skills regarding complex cases and clients go to our cores as counselors and as human beings. Interestingly, each of us was concerned with the ways in which her own level of clinical experience would influence group dynamics as well as her ability to
P1: FLF Journal of Genetic Counseling [jgc]
402
HS105-81
August 17, 2000
16:2
Style file version Nov. 19th, 1999
Hiller and Rosenfield
contribute to the group. For more recent graduates, the worries took the form of a perceived “lack of experience”: Would they have as much to contribute? Would their interventions be viewed as less insightful? Others had changing job situations and were concerned that their different responsibilities would mean that they would have less to offer the group. Still others worried that differences in experience might translate into a hierarchy within the group that would have a negative impact on our interactions. In making the financial and time commitment to create this group, we recognized that we would need to invest even more at an emotional level in order to get our “money’s worth.” The hope was that in taking the risk to reveal ourselves, the value gained through our discussions and the safety provided by the setting would far exceed any personal discomfort we might experience.
EXPERIENCES OF GROUP MEMBERS Dr. Kennedy was instrumental in assembling the supervision group. She contacted each of us individually after hearing of our interest and provided a template for how the group would function. During our first meeting, she supported our hopes for what the group could become by sharing her own experience with postgraduate clinical supervision and its value in her professional life. She listened carefully to our concerns. She focused on concrete elements such as the proposed structure for the group and the value of case review in a counseling context. Without a long-term commitment, we had the freedom to view the first six sessions as a trial period and to see just where the group would go. Creating the supervision group became do-able. We did not feel overwhelmed by either our expectations or our concerns. The first group meeting was decidedly awkward. Although we all knew each other to varying degrees, this was a brand new and somewhat intimidating context. The existing relationships among various members added a challenge to the task of forming a group of equals or peers. Some of us had met each other only in passing at professional conferences, while others were colleagues at the same work site or even had long-standing friendships. Two of the counselors had served as supervisors to a third during her student internships. Some of us had been Dr. Kennedy’s students at Brandeis University. We would eventually come to be able to discuss these very issues as part of our process, but during the first meeting, we needed to reintroduce ourselves to each other in the context of this new setting. The source of our equality became clear in the form of our goals; each of us, regardless of experience, wanted to keep growing professionally and had chosen this format in which to do it. During this first meeting, we took time to individually describe our counseling practices and work settings as well as our goals for supervision.
P1: FLF Journal of Genetic Counseling [jgc]
HS105-81
August 17, 2000
The Experience of Leader-Led Peer Supervision
16:2
Style file version Nov. 19th, 1999
403
The first six sessions, occurring over twelve weeks, passed quickly. Each of the six participants had the opportunity to present one or two cases during that time. By the end of the twelve weeks, all of us wanted to continue because we had benefited from those first meetings. We all wanted to present other cases. It seemed clear that the first six meetings represented just the tip of a very intriguing and productive iceberg. With the high level of interest in continuing the group, it was necessary to establish guidelines for going forward including procedures for leaving the group and bringing new members aboard. Specifically, if a member wished to leave the group, that member could not leave abruptly. We agreed that a period of two to three more meetings would be necessary to process the leaving and say goodbye. Likewise, if someone were interested in joining the group, she would be referred to Dr. Kennedy who would then approach the group members regarding the possibility of adding a new member. This discussion might also span two to three sessions. A group consensus was necessary for inclusion of a new member to the group. It was also agreed upon that we would periodically devote group time to a discussion of ways in which to ensure that the group continued to meet our needs and sustain our interest. This review would begin with a presentation by Dr. Kennedy of a compilation of themes that had surfaced in our discussions. Also as a part of the periodic review, group members would discuss the impact of the group for each of us individually. Several factors have contributed to the longevity of our supervision group. Simply stated, our expectations were exceeded and our fears proved largely unfounded. The safety and trust that now exists within the group grew incrementally. An early event indicating trust occurred with a shift from presenting past cases to current problematic cases. If it is difficult to open oneself up to scrutiny about events that are long over, it is doubly difficult to do so with ongoing cases. While building a safe environment was essential in the beginning, once established it allowed us to critique and challenge each other. Gradually, we found ourselves able to raise very sensitive issues for discussion, including job frustrations and personal challenges and how they affected our work. We changed the group format by devoting time at the beginning for updates and new thoughts about old cases. It also became “open” time for us to bring up important personal issues and milestones. Settling into this new format allowed us to continue to connect to one another personally and professionally. The group has established a safe environment in large part because we set appropriate boundaries and the members respected those boundaries. As the trust in those boundaries grew, so did our willingness to take risks. As part of the original contract, we all agreed that we would not discuss the group or issues raised by the group with “outsiders.” We also agreed that we would not discuss issues or dynamics important to the entire group with one or just a few members of the group. Our concern was that this might lead to an unhealthy change in group dynamics. There was the acknowledged issue of patient and professional
P1: FLF Journal of Genetic Counseling [jgc]
404
HS105-81
August 17, 2000
16:2
Style file version Nov. 19th, 1999
Hiller and Rosenfield
confidentiality, but moreover there was the need to demonstrate respect for our colleagues. It is likely that the shift to on-going cases is connected to the establishment of appropriate boundaries. We all had to know that the group could hear our most challenging and troubling cases. Since we are being critiqued without being judged, we can experience the group discussion as helpful in strategizing the next step. In addition, we can prod each other to seek greater understanding of what happened in our sessions and, more importantly, our reactions to those events. We take new insights back to our work settings and incorporate them in ways that work for us individually. We remain individuals with distinct counseling styles that are not fundamentally altered, but are augmented by group feedback. The knowledge that we may take risks without being personally attacked makes the group setting safe and creates the space for personal growth and professional development. With a shift from past cases to current cases, the emphasis is placed on interventions that can be actively employed. We accomplish this through the use of role-play, journal reading to apply theory, suggesting and “trying on” interventions, and providing support. Each of these facilitates conscious awareness of factors that may obstruct the counseling process. Using role-play and integrating theory can help an individual counselor change her approach to a difficult patient or set of circumstances. Continuity is provided by the time devoted to follow-up at the beginning of each supervision session. This establishes a comfortable flow and a connection to our past cases and to each other. While the supportiveness of the group has been tremendously important to its success and longevity, we do challenge each other. One form that this takes is a probing assessment of interventions that have been employed by the presenter and the suggestion of alternative approaches. This is true both for finished cases and for those that are ongoing. Examples of questions designed to challenge are “What if you had said . . . to this patient?” or “If you had done . . . instead of the intervention used, how do you think the interaction would have changed?” This approach solicits creative thinking about cases and may involve imagining several alternative interventions. We try to include interventions that are unconventional, provocative, or even outrageous as an exercise to stretch our own limits, even though many approaches would never be employed in a counseling session. On occasion, roleplay has been especially useful. In one instance, a counselor was dreading making a phone call to a particularly demanding and unpredictable patient. Role-playing the call and a number of possible interactions gave her the opportunity to practice and solidify her approach to a potentially unpleasant and difficult interaction. It also gave the group a chance to critically examine the counselor’s proposed approaches, suggest other possibilities, and ask her to “report back” about the phone call at the next meeting. In addition to assessing the specifics of patient interactions in particular cases, we challenge each other to identify and address our own biases, patterns, and issues,
P1: FLF Journal of Genetic Counseling [jgc]
HS105-81
August 17, 2000
The Experience of Leader-Led Peer Supervision
16:2
Style file version Nov. 19th, 1999
405
particularly those that might produce obstacles to the counseling process. We try to press beyond what is apparent in the case and examine our own defenses, reactions to patients, and perceptions of ourselves as counselors. Examples of questions that get at these issues are “Why was the interaction with this patient difficult for you?” “Did this patient behave in a manipulative way or did you allow yourself to be manipulated?” “Did you make assumptions about the patient based on ethnicity/class/gender/age?” “How has your personal or family experience with chronic illness affected your interaction with this patient?” All of these questions fall broadly under the heading of “Don’t you think that there is something else going on here?” and can be some of the most uncomfortable and revealing to discuss. One group member presented a case in which she felt that she had abandoned her opinions about a case and her role in patient care too easily when she disagreed with a physician at work. Lengthy discussion in the group revealed that the counselor has had a pattern of “abdication” to perceived authority and of undervaluing herself professionally. Each of us feels some anxiety about presenting difficult cases and being in the “hot seat” as the counselor to be critiqued during a meeting. This would not be the case if our group were simply a comfortable social gathering. However, we do not believe that supervision must always be painful or can never be fun. In fact, we find that we often use humor as a way to manage tension about a case, feelings of inadequacy, or interactions in the group that become heated or uncomfortable. At the same time, we try to be aware of these light moments and the purpose that they are serving and not hide behind humor. Some sessions are less personally challenging than others and we do not subscribe to a “no pain, no gain” philosophy. There is great value in the amount of time and depth of discussion that we are able to give to each case. It is a delicate balance of support and criticism, humor and seriousness that allows our group to function.
KEY MOMENTS The accompanying articles include three detailed descriptions of case presentations that will provide the reader with more sense of the workings of our supervision group. In this section, we describe several developments or situations that were pivotal to the evolution of our group. They represent only a small sample of the many events that have shaped the group. Early in the development of the group, it took some time to settle on the best format for the use of our hour and a half together. Initially, we tried to have two case presentations in a single evening. We soon realized that there was always enough material from a single case to fill the entire time in a satisfying way. In fact, trying to get through two presentations felt like a push; feeling rushed and hectic was the last thing that we wanted for our processing time. The format of
P1: FLF Journal of Genetic Counseling [jgc]
406
HS105-81
August 17, 2000
16:2
Style file version Nov. 19th, 1999
Hiller and Rosenfield
one case per session, with time at the beginning for updates and news, was a very productive one for us. More recently, we have elected to meet once a month for two hours. The format is essentially the same except we now have time to present a second case. We found that scheduling conflicts were frequent when we attempted to meet every other week. We are still in the “trying out” phase of this latest arrangement and suspect it will continue to change over time as the needs of the group change. At the end of the first year, there was a general consensus that we would like to “take it to the next level” and challenge ourselves further. One approach to doing this, suggested by Dr. Kennedy, was to incorporate articles from the psychology and counseling literature into our case presentations. In this way, cases may be discussed and explored within particular theoretical frameworks. Some of the articles and chapters that we have used are listed in Appendix A. The majority of this list has come from a core set of readings provided by Dr. Kennedy. However, group members have added articles of personal interest and relevance to our cases. Not every case is presented along with literature or theory, but this gives us an option for enriching presentations. For cases involving issues of suicide, guilt and shame, and personality disorders—to name a few—incorporating articles from the literature has been invaluable for centering our discussions. In addition to incorporating theory, an approach that we have just begun to use is to specifically analyze our personal biases and explore how they may surface in the handling of particular cases. All people, counselors included, hold strong beliefs about disability, religion, socioeconomic status, ethnicity, and race among many other issues. By consciously examining these beliefs, we can come to understand how they may surface in our counseling sessions in obstructive ways. While it is not the aim of the group to work through or alter the biases of its members, we do try to help each other identify areas where personal issues may affect counseling approach. While acknowledging that we all have biases, we try to develop strategies to manage their influence on our counseling interactions. Another example of stretching the limits of the group occurred in response to a counselor’s request that Dr. Kennedy present a case from her own practice. This has not become a regular feature of the group and, as a regular occurrence, would not fit within the usual boundaries of the facilitator’s role. However, this one case presentation allowed Dr. Kennedy to share of herself in a more personal way and gave the group a better appreciation for her counseling style and interventions. Dr. Kennedy became more real to us as a therapist. As she shared her thoughts and feelings about her patient—and her own experience in clinical supervision—we could see that professional development is always a work in progress, requiring attention and continual refinement. Countless situations and discussions have engendered the closeness and trust that we now feel, but several stand out in our memories. On one occasion, a group member described how she cried in front of a student in her office after a
P1: FLF Journal of Genetic Counseling [jgc]
HS105-81
August 17, 2000
16:2
The Experience of Leader-Led Peer Supervision
Style file version Nov. 19th, 1999
407
particularly sad session with a patient. This had felt to her at the time like a loss of control, a “break-down,” even an unprofessional loss of composure. The group affirmed the humanity and validity of her reaction and the possible benefits for her student of seeing a supervisor care about a patient so deeply. On another occasion, the group was able to openly discuss the differences in experience among its members as well as discomfort experienced by the change in some of our relationships from pregroup associations. The honesty caused many barriers to fall that evening. A former “student” felt more comfortable commenting on her “supervisor’s” cases. Group members who were not currently seeing patients were reassured that they made as valuable a contribution as those who were. We reached the sincere consensus that diversity in all areas—clinical experience, temperament, counseling style, personal circumstances—enriches the group a great deal. Still another session dealt with the extreme job-related stress faced by one member whose work demands had become unreasonable. All of us had discussed to some extent feelings of burnout, isolation, or being undervalued, but those feelings crystallized that night in her situation. The group helped bolster her resolve to be assertive enough to ask for the specific changes at work that would make her circumstances more pleasant, and in fact she did get much of what she asked for. The group also assured her that her current situation did not reflect negatively on her as a counselor and that no one would be able to fulfill all of the expectations placed upon her. It became increasingly clear that not only was it acceptable for her to ask for reasonable changes at work, but that in fact it was necessary in order for her to take care of herself. Some issues have surfaced in the context of particular cases that have served to strengthen the bonds within the group. One member expressed feeling guilty about the fact that she occasionally has patients that she simply doesn’t like, leading to the acknowledgment that this was a situation common to all of us. It was a relief to share this sentiment and process it, realizing along the way that it doesn’t diminish us as genetic counselors and that we are still able to provide good care to these patients. Many cases have involved feelings of failure; all of us have wished that we could have helped a patient more, handled interactions with a couple better, or felt more competent with a manipulative or intimidating patient. The group has been consistently effective in turning these perceived failures into learning opportunities.
SUPERVISION TOPICS We have surprised ourselves with the number of topics that we bring to the group. Table I represents a brief sampling of those issues. Some issues seem to continually reemerge because they represent the situations and crises that are faced
P1: FLF Journal of Genetic Counseling [jgc]
HS105-81
August 17, 2000
16:2
Style file version Nov. 19th, 1999
408
Hiller and Rosenfield Table I. Examples of Discussion Topics Patient-related issues Challenging patients Learning disabilities Mental illness and personality disorders Mental retardation Suicidality and suicide Domestic violence Level of directiveness Counselor-related issues Work environment Transference and counter-transference Confidentiality Reframing issues Personal biases Personal /professional boundaries Burnout Group process Student supervision
by people seeking genetic counseling. Others seem to be inherent to the experience of counselors or the interactions between counselor and patient. It is never dull or wasteful to revisit the same general topics because what can be gleaned from a given case depends upon so many factors. We change over time, our jobs change, and each patient interaction is unique. CONCLUSION The model of leader-led peer supervision, long used in other mental health professions, has proven to be a rewarding format for this group of genetic counselors. It is well suited to the professional development needs of genetic counselors and is a particularly appropriate way to address growth in counseling skills; many avenues already exist for keeping current in the scientific component of our profession. While we are eager to tell our colleagues about the success of our group, it is important to add that we needed time together in order for our group to come to this stage of development. A newly formed group would need to acknowledge that the connection to one’s colleagues and the commitment to the supervision process occur in stages. The first few cases presented are the most difficult and everyone will not move at the same pace. As with our clients, some of us share personal difficulties more readily than others do. Each group will also need to experiment and find the correct format and style to fit the needs of its members. We have found our supervision group to be such a worthwhile endeavor that the inevitable growing pains experienced in the beginning have been far outweighed by the benefits.
P1: FLF Journal of Genetic Counseling [jgc]
HS105-81
August 17, 2000
The Experience of Leader-Led Peer Supervision
16:2
Style file version Nov. 19th, 1999
409
APPENDIX A Baker DL, Schuette JL, Uhlmann WR (1998) A Guide to Genetic Counseling. New York: Wiley-Liss. Bronfenbrenner U (1977) Toward an experimental ecology of human development. American Psychologist 32:513–531. Carter B, McGoldrick M (1988) Overview. In: The changing family life cycle: A framework for family therapy. New York: Gardner, pp 3–28. Cohen R (1994) About men: Waiting. The New York Times Magazine Jan 16. Eunpu DL (1997) Systemically-based psychotherapeutic techniques in genetic counseling. J Genet Couns 6:1–20. Erikson EH (1963) Eight ages of man. In: Childhood and Society. New York: WW Norton & Co. Finucane B (1998) Working with women who have mental retardation: A genetic counselor’s guide. Elwyn: Elwyn, Inc. Gilligan C (1993) Concepts of self and morality. In: In a different voice. Cambridge: Harvard University Press. Glossary of specific defense mechanisms and coping styles (1994) In: Diagnostic and statistical manual of mental disorders, 4th ed (DSM-IV). Washington, DC: American Psychiatric Association, pp 755–757. Green R (1992) Letter to a genetic counselor. J Genet Couns 1:55–69. Green R (1994) Another letter to a genetic counselor. In: A Heartbreaking Choice. St. John’s, MI: Pineapple Press. Hamilton NG (1992) Countertransference. In: Self and others: Object relations theory in practice. New Jersey: Aronson, pp 235–250. Horowitha M, Marmar C, Krupnick J, Wilner N, Kaltrieder N, Wallerstien R (1984) Our approach to brief therapy: Focused on current stressors. In: Personality styles and brief psychotherapy. New York: Basic Books, pp 34–50. Hoyt MF, Rosenbaum R, Talmon M (1992) Planned single-session psychotherapy. In: Budman SH, Hoyt MF, Freidman S (eds) The First Session in Brief Therapy. New York: Guilford, pp 59–86. Jordan JV (1991) Empathy and the mother-daughter relationship. In: Jordan JV, Kaplan AG, Miller JB, Stiver IP, Surrey JL Women’s growth in connection: Writings from the Stone Center. New York: Guilford, pp 28–34. Kessler S (1979) The genetic counselor as psychotherapist. Birth Defects: Original article series (The National Foundation) 25:187–200. Kessler S, Kessler H, Ward P (1984) Psychological aspects of genetic counseling III: Management of guilt and shame. Amer J Med Genet 17:673–697. Kessler S (1972) Psychological Aspects of Genetic Counseling VII: Thoughts on Directiveness. J Genet Couns 1:9–17. Kessler S (1997) Psychological aspects of genetic counseling IX: Teaching and counseling. J Genet Couns 6:287–295. Kessler S (1997) Psychological aspects of genetic counseling X: Advanced counseling techniques. J Genet Couns 6:379–392. Kessler S (1997) Psychological aspects of genetic counseling XI: Nondirectiveness revisited. Amer J Med Genet 72:164–171. Kessler S (1998) Psychological aspects of genetic counseling XII: More on counseling skills. J Genet Couns 7:263–278. Kluger-Bell K (1998) Lost fathers: Men’s experience of pregnancy loss and abortion. In: Unspeakable losses: Understanding the experience of pregnancy loss, miscarriage and abortion, pp 99–117 & pp 135–147. Massie RK, Jr (1985) The constant shadow: Reflections on the life of a chronically ill child. In: Hobbs N, Perrin J (eds) Issues in the care of children with chronic illness. San Francisco: Jossey-Bass, pp 13–23. Matloff ET, Eunpu DL, Djurdjinovic L (1997) Generations lost: A cancer genetics case report and commentaries. J Genet Couns 6:169–180. McGoldrick M (1982) Ethnicity and family therapy: An overview. In: McGoldrick M, Pearce JK, Giordano J (eds) Ethnicity and family therapy. NY: Guilford, pp 3–30.
P1: FLF Journal of Genetic Counseling [jgc]
410
HS105-81
August 17, 2000
16:2
Style file version Nov. 19th, 1999
Hiller and Rosenfield
Michie S, Marteau TM (1996) Predictive genetic testing in children: The need for psychological research. Brit J Health Psychology 1:3–14. Mitchell DR (1985) Guidance needs and counseling of parents of persons with intellectual handicaps. In: Singh NN, Wilton KM (eds) Mental retardation in New Zealand: Provisions, services and research. Christchurch, New Zealand: Whitcoulls, pp 136–156. Noble JH (1987) Ethical considerations facing society in rehabilitating severely disabled persons. In: Ferrari M, Sussman M (eds) Childhood disability and family systems. New York: Haworth, pp 65–81. Olson DH, Russell CS, Sprenkle DH (1983) Circumplex model of marital and family systems VI: Theoretical update. Family Process 22:69–83. Perry CH (1982) Models of development, relationship and therapy in the work of Donald Winnicott. Unpublished manuscript. Peters JA (1994) Suicide prevention in the genetic counseling context. J Genet Couns 3:199–213. Peters-Brown T, Fry-Mehltretter L (1996) Genetic counseling for pregnant adolescents. J Genet Couns 5:155–168. Pipes RB, Davenport DS (1990) Transference/countertransference. In: Introduction to psychotherapy. Englewood Cliffs: Prentice Hall, pp 151–166. Pueschel SM (1991) Ethical considerations relating to prenatal diagnosis of fetuses with Down Syndrome. Mental Retardation 29:185–190. Sedney MA, Baker JE, Gross E (1994) “The story” of a death: Therapeutic considerations with bereaved families. J Marital Fam Ther 20:287–296. Surrey JL (1991) Empathy and the mother-daughter relationship. In: Jordan JV, Kaplan AG, Miller JB, Stiver IP, Surrey JL Women’s growth in connection: Writings from the Stone Center. New York: Guilford, pp 51–66. VanPutte AW (1988) Perinatal bereavement crisis: Coping with negative outcomes from prenatal diagnosis. J Perinatal Neonatal Nursing 2:12–22. Welshimer KJ, Earp JL (1989) Genetic counseling within the context of existing attitudes and beliefs. Patient Education Couns 13:237–255. Wikler L, Wasow M, Hatfield E (1981) Chronic sorrow revisited: Parent vs. professional depiction of the adjustment of parents of mentally retarded children. Amer J Orthopsychiatry 51:63–70. Wikler L (1981) Chronic stresses of families of mentally retarded children. Fam Relations 30:281–288. Wikler L, Wasow M, Hatfield E (1983) Seeking strengths in families of developmentally disabled children. Social Work 28:313–315. Worden JW (1991) Grief counseling: Facilitating uncomplicated grief. In: Grief counseling and grief therapy: A handbook for the mental health practitioner, 2nd ed. New York: Springer, pp 37–62. Yarborough M, Scott JA, Dixon LK (1989) The role of beneficence in clinical genetics: non-directive counseling reconsidered. Theoretical Medicine 10:139–149.
